AFFIDAVIT RE

Attachment 4

ACCEPTING PROVISIONS OF THE WORKMEN’S COMPENSATION ACT

State of )

) ss:

County of ) he has being duly sworn according to law deposes and says that they have it has accepted the provisions of the Workmen’s Compensation Act of 1915 of the Commonwealth of Pennsylvania, with has his its supplements and amendments, and have insured their liability thereunder in accordance with the terms of said its

Act with .

(SURETY COMPANY)

( TYPE OR PRINT) CONTRACTOR

BY

SIGNATURE

Sworn to and subscribed before me this day of A.D. 20 .

SIGNATURE

My Commission Expires ( DATE )

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D-7126 ( 7-09 )

ANTI-COLLUSION AFFIDAVIT

County Berks

Municipality Earl Township

Project Number 2026 Road Work

State of Fed. Project No.

( If Applicable )

County of

The undersigned deponent deposes and says that he is the ____________________ of the Company; that he is authorized to make this affidavit on behalf of said company in compliance with section 102.06 (e) of Department Specifications, Publication 408, as amended and that the said company has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with such contract.

(Contractor)

BY

Sworn to and subscribed before me the undersigned notary public this day of , .

Notary Public

My Commission expires

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Rev 2/15 PSATS CDL Program Form Contractor

Contractor’s Statement of Compliance with

CDL Testing Program Requirements

Due to the nature of the work that this contractor may perform for this employer, this contractor must use employees who perform safety-sensitive functions for which a Commercial

Driver’s License (CDL) is typically required. Section 49 CFR 382.301(c)(2) of the federal CDL regulations requires that, prior to the first time an employer uses a CDL employee employed by another entity (i.e., a contractor to whom the township is awarding a contract), and every six months of the contract, this employer must certify that any CDL employees used by each contractor remain covered by a qualified CDL drug and alcohol testing program.

An original signed copy of this form must be permanently retained by the employer with this contract and a new form received every 6 months of the contract’s duration.

If the contractor is not participating in a qualified CDL drug and alcohol testing program at the time of the awarding of the contract, or at any six-month re-certification point, then all the contractor’s CDL employees must obtain a negative result on a pre-employment drug test before beginning (or continuing) contracted work for this employer.

Contractor Name__________________________________________________________________________

By signing here, I, as the contractor’s authorized representative, verify that the contractor named above is a current participant in the below identified CDL testing program conforming to 49 CFR Part 40.

Contractor’s Authorized Representative ________________________________________________________

Today’s Date ____/____/____

Signature of Authorized Representative ________________________________________________________

CDL Testing Program Name ________________________________________________________________

Testing Program Contact Person ____________________________________________________________

Testing Program Address __________________________________________________________________

Phone #: ( ) City ______________________________ State _____ Zip __________

Contact person confirms program conforms to 49 CFR Part 40? (_____) Yes (______) No

Contact person confirms list of contractor’s CDL employees covered in this program and that all drivers are qualified to driver under 49 CFR Part 382.301? (_____) Yes (______) No

Commonwealth of Pennsylvania

Public Works Employment Verification Form

Public Works Employment Verification Office Department of General Services Bureau of Procurement 6th floor, Forum Place 555 Walnut Street

Harrisburg, PA 17101-1914

717-346-8115 ra-gsgseverify.pa.gov

Instructions: Complete and return the form to the contracting Public Body prior to the award of the contract.

Business or Organization Name (Employer)

Address

City State Zip Code

Check One:

Contractor

Subcontractor

Contracting Public Body

Contract/Project No.

Project Description

Project Location

Date enrolled in E-Verify

As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of the above date, our company is in compliance with the Public Works Employment Verification Act (‘the

Act’) through utilization of the federal E-Verify Program (EVP) operated by the United States

Department of Homeland Security. To the best of my/our knowledge, all employees hired post January

1, 2013 are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal

EVP upon each new hire shall be maintained in the event of an investigation or audit.

I, , authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

Authorized Representative Signature Date of Signature